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Based on policy review, review of Medical Staff Rules and Regulations, medical record review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) with psychiatric conditions were stabilized within the capabilities of the hospital or appropriately transferred to another facility for 1 of 22 (Patient #1) sampled patients and failed to ensure transfer documentation was included in the medical record for 1 of 22 (Patient #1) sampled patients.

The findings included:

1. Patient #1 was a 77 year old female, nursing home resident, transported via emergency medical services (EMS) to Hospital #1's ED on 7/17/2023 at 3:58 PM with complaints of a psychiatric episode with aggression. Patient #1 received a medical screening exam which ruled out medical complications and determined she required inpatient psychiatric care. Patient #1 was evaluated by Mobile Crisis and Psychiatric services, and Master Social Workers, who agreed the patient required inpatient psychiatric care. Patient #1 required 1:1 monitoring while she was in the ED to ensure her safety. Patient #1 refused all medications in the ED, including her psychiatric medications. Patient #1 remained in the ED waiting inpatient psychiatric care from 7/17/2023 through 7/20/2023. Case Management determined Patient #1 was out of Medicare Psychiatric days. Case Management documented on 7/20/2023, the nursing home agreed to take Patient #1 back if the Psychiatrist would provide documentation Patient #1 was not a danger to herself or others. Patient #1 was discharged back to the nursing facility without stabilizing care and services on 7/20/2023 at 7:37 PM.

Patient #1 was transported back to Hospital #1 on 7/20/2023 at 11:12 PM for psychiatric needs. Patient #1 remained in Hospital #1's ED with 1:1 monitoring and care until she was transferred to Hospital #2 on 8/2/2023 for inpatient psychiatric care. Hospital #1 failed to document the required transfer paperwork in Patient #1's medical record.

Refer to A 2407 and A2409.

Based on policy review, review of Medical Staff Rules and Regulations, medical record review, emergency medical services (EMS) report, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) with psychiatric conditions were stabilized within the capabilities of the hospital or appropriately transferred to another facility for 1 of 22 (Patient #1) sampled patients.

The findings included:

1. Review of the hospitals "Emergency Medical Treatment and Active Labor (EMTALA) policy revised on 2/5/2021 revealed,"... The purpose of this policy is to define the relevant terms and provide and overview of the Emergency Medical Treatment and Labor Act (EMTALA), the regulations and rules promulgated thereunder, and the State Operations Manual interpretive guidelines. This Emergency Medical Treatment and Patient Transfer policy is based on federal law relating to the obligations of hospitals to provide screening and emergency medical treatment and the appropriate transfer of individuals between hospitals. The treatment and transfer of an individual shall not be predicated upon arbitrary, capricious, or discrimination based upon race, color, religion, national origin, age, sex, sexual orientation or identification diagnosis, physical condition, economic status, payer source, ability to pay, or other protected category...DEFINITIONS...Emergency Medical Condition means: A medical condition manifesting by acute symptoms of sufficient severity (including...psychiatric disturbances...) such that the absence of immediate medical attention could reasonably result in: Placing the health of the individual in serious jeopardy...With respect to an individual with psychiatric symptoms: That acute psychiatric...symptoms are manifested. That the individual is expressing suicidal or homicidal thoughts or gestures and is determined to be a danger to self or others...Stabilized/Stabilization:...Stabilized means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual...Stable for Discharge: A patient is stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or the patient requires no further treatment and the treating physician has provided a written documentation of his or her findings...Stabilizing Treatment If it is determined through MSE that an EMC exists...ED personal shall: (1) provide such further medical examination and treatment as may be required to stabilize the medical condition ...within the capabilities of the staff and facilities available at the hospital or (2) transfer the individual to another appropriate facility that can meet the patient's needs ... For behavioral health emergencies, a patient is considered stable for transfer when he/she is protected and prevented from harming self or others...

2. Review of the Medical Staff Rules and Regulations, with the most recent approval dated 3/20/2023, revealed, "...Emergent patients are defined as patients who meet the following EMTALA criteria for having an 'emergency medical condition' A medical condition manifesting itself by acute symptoms of sufficient severity (including...psychiatric disturbances...) such that the absence of immediate medical attention could reasonable be expected to result in: 1) serious jeopardy to the health of the individual 2) Serious impairment to bodily function; or 3) Serious dysfunction of any bodily organ ...with respect to an Emergency Medical Condition, stabilize means: To provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result or occur during the transfer of the individual from a facility...Psychiatric...Care:[named Hospital #1] does not provide inpatient treatment for patients who have psychiatric...problems. When a patient presents to the Emergency Department (ED) with a psychiatric...problem they will be evaluated in the ED. If the patient is medically stable the patient will have disposition determined in the ED...The Medical Staff treating the medical condition may request psychiatric consult for co- management during the hospitalization..."

3. Medical record review for Patient #1 revealed she was transported from a nursing facility via Emergency Medical Services (EMS) to Hospital #1 on 7/17/2023 at 3:58 PM. Review of the EMS trip report revealed Patient #1 was a 77 year old female with Behaviors/psychiatric episode and altered mental status. The EMS narrative revealed, "Called to nursing home, along with law enforcement, for patient reported to be a psychotic episode ...was told patient had been aggressive with staff...had not been taking medications...Patient would cooperate with EMS and ambulated to cot with little difficulty. Patient definitely seemed disoriented and believed she was in several different places...About mid-way through transport, patient removed blood pressure cuff and would not allow its use. No further difficulties during transport..." EMS transitioned Patient #1's care to Hospital #1 ED staff at 4:00 PM.

Triage was initiated on 7/17/2023 at 4:00 PM and Patient #1 was assigned an acuity level 3. The medical Screening exam (MSE) was initiated at 4:03 PM by Physician #2. Physician #2 History and Present Illness documentation revealed, "This is a 77 year old female with past medial history significant for the fact that she has hypertension, hyperlipidemia, Type 2 diabetes, hypothyroidism, schizoaffective disorder, dementia with psychotic disturbance, who presents to the emergency room from [named nursing facility] for refusing to take her medications and acting out towards staff. My history comes from paperwork sent over from her nursing care facility, as well as the paramedics who brought the patient. Patient has a long standing psychiatric history, and has been here in the emergency room multiple times in the past for the same....Paramedics told me that she accuses every male of either being married to her in the past or trying to assault her. When I walked in the room, the patient does not answer questions of orientation. She tells me that I want to marry her, and she does not want to marry me. She states that I used to be a priest. She then states that I was on TV, and she saw me on TV. She called me a bastard multiple times. She told me not to touch her when I attempted to so a physical exam, and to get out of her room. Further history is completely limited secondary to her dementia with psychosis." Physician #2 documented Patient #1 was combative during her Electrocardiogram (EKG) and refused to be still making it difficult to get a good EKG. Patient #1 had the following laboratory for medical decision making: Complete Blood Count, Thyroid panel, urine drug screen, urinalysis, Prothrombin, Covid test, Comprehensive Metabolic Panel. Physician #2 documented, "Based upon my history, physical examination, and my independent review and interpretation of the patients laboratory tests, the patient does not have a medical condition requiring further evaluation in the emergency room or as an inpatient in the hospital. There are abnormalities in the patients labs, but these are reflective of the patient not being medicated...Were it not for the fact that the patient is suffering from an acute psychiatric emergency, the patient would be discharged home to follow-up any medical complaints with primary doctor ...it is more reasonable to pursue inpatient or outpatient psychiatric treatment." Physician #2 completed a Certificate of Need for Emergency Involuntary Admission to a psychiatric facility on 7/17/2023 at 5:08 PM which documented Patient had a history of schizoaffective disorder and dementia, along with disorganized thoughts putting the patient in substantial risk of harm, with lack of inpatient care resulting in potential harm to the patient. Physician #2 documented Patient #1 was not appropriate for outpatient management and did not have the ability to contract for safety. Patient #1 was placed on 1:1 monitoring, for safety precautions in the ED, on 7/17/2023 at 4:00 PM.

Review of Behavioral Health assessment from the ED MSW #2 dated 7/17/2023 at 5:26 PM revealed, "...Pt [patient] is alert disorganized, disoriented X [times] 4 and talkative, but refuse to answer some of the questions. Pt is having delusions of grandiose. Pt states she is married to ten husbands to include basketball player Lebron, Rod Stewart and Michael Jackson. Pt reports her name is...Pt appears to be having auditory hallucinations ...pt is easily anger and can become physically aggressive...Recommendation is for inpatient facility by social worker and [named Physician #2]."

Review of Patient #1's medications revealed the following were ordered to address her psychosis/dementia and behaviors in Hospital #1's ED:
7/17/2023- Depakote 500 milligram tablet twice daily and discontinued on 7/20/2023 at 8:31 AM.
7/17/2023- Aricept 5 milligram tablet once daily at bedtime.
7/17/2023-Risperidone 4 milligram tablet twice daily and discontinued on 7/20/2023 at 8:31 AM.
7/17/2023-Geodon 40 milligram capsule twice daily and discontinued on 7/20/2023 at 8:31 AM.
7/20/2023-Haldol 5 milligrams twice daily.

Review of medication administration records revealed Patient #1 refused all medications in the ED from 7/17/2023 until she was discharged on 7/20/2023, with the exception of 2 administrations of a Dulera inhaler on 7/18/2023 at 7:38 AM and 7/19/2023 at 9:19 AM.

Review of a Nurse Practitioner note dated 7/18/2023 at 2:34 AM revealed, "...Patient presents with a psychiatric problem. Today is day #2. Pt [patient] is in the ED for psychiatric evaluation and management...completed 6404 [involuntary psychiatric admission]...on chart...Pt is pending placement and transfer to psych facility. Per physician, inpatient is indicated for this patient..."

Review of Psychiatric consult notes by Physician #1 dated 7/18/2023 at 8:14 AM revealed Patient #1 was seen by Physician #1 via telemedicine revealed the patient had previous psychiatric hospitalizations, had a diagnosis of schizoaffective disorder with a plan to "restart home meds Look for placement"

Review of the mobile crisis assessment dated 7/18/2023 initiated at 10:00 AM via televideo revealed, "Ct [client] presented to [named hospital #1] from [named nursing facility] Ct presented for assessment w/ [with] appropriate grooming and mostly clear speech. Ct mood is angry and affect is congruent. Ct is alert but disoriented to person...Ct increasingly agitated during assessment and ER staff report that affect has been labile throughout her stay. Ct refuses to answer most of MCS [Mobile crisis services] questions. She reports her name is [used alternate name not that of the patient] and becomes extremely agitated when called [by own name]...Assessment was terminated at this timed/t [due to] ct repeatedly stating 'Bye-bye' and becoming increasingly agitated. Throughout assessment ct can be observed attending to internal stimuli. She at no time responds appropriately to MCS questions. Due to AMS [altered mental status] and psychosis, ct does appear to be appropriate for a higher level of care. Per Access center [Hospital #1's corporate behavioral health services], ct does appear to be out of Medicare days for IPMH [inpatient mental health care] at this time and is therefore considered uninsured for IP [inpatient] care. Case was staffed with [named mobile crisis supervisor] who agreed that, although ct is in need of stabilization, she is not appropriate for [named state psychiatric hospital for Middle Tennessee region] d/t no geriatric care provision at [named state psychiatric hospital for Middle Tennessee region]. Therefore, it is recommended that ct continue to be assessed by Access [Hospital #1's corporate behavioral health services]/ [named Physician #1] for medication evaluation and stabilization at this time."

Review of Case Management notes by MSW #1 dated 7/18/2023 at 6:50 PM revealed, "Received update from mobile crisis regarding the status of this patient. Per crisis, the patient is out of Medicare IP days, and considered uninsured. Although [named state psychiatric hospital for Middle Tennessee region] is currently the state facility for uninsured individuals, she is currently not eligible to be referred due to their not offering services to elderly individuals. Because of this, the recommendation of mobile crisis is that she remain here for and be treated by [named Physician #1] until the nursing home is willing to take her back. This writer contacted the nursing home, and they are currently not willing to take her back until she is exhibiting 'no more behaviors' The patient currently refuses to take medications and see [named Physician #1]. At this time, it appears to be the recommendations of [named state psychiatric hospital for Middle Tennessee region], crisis and the nursing home that she remain in the ER indefinitely."

Review of a Physician Assistant note dated 7/20/2023 at 3:37 AM revealed, "...It sounds like the patient has behavioral health problems within the nursing home that the nursing home does not feel comfortable dealing with. The patient also does not meet criteria for inpatient behavioral health. Case management will have to continue to work on finding placement for this patient..."

Review of Psychiatric progress notes by Physician #1 dated 7/19/2023 at 9:17 AM revealed "...No new complaints. Compliant with meds [not accurate based on medical record documentation]. Remains very agitated and labile. Cursing." The plan remained "restart home meds, look for admission."

Follow up notes from mobile crisis dated 7/19/2023 at 10:44 AM revealed, "... [named Physician #1] assessed ct this morning and is recommending IP placement..."

Review of the Psychiatric progress notes by Physician #1 dated 7/20/2023 at 8:33 AM revealed, "...no new complaints, she is refusing to be interviewed properly. She thinks she is Sierra and waiting for Rod Stewart. She has been denied by other facilities..." The plan was documented as "DC Risperdal and Geodon Start Haldol 5 milligrams twice daily. Pt will need treatment review for forced meds. Look for admission..."

Follow up notes from mobile crisis dated 7/20/2023 at 10:00 AM revealed, "MCS spoke with [named nurse in ED] who reports that [named Physician #1] saw ct again this morning for the second time, and is feeling that Ct still requires stabilization. Ct is out of Medicare days, but inappropriate for [named state psychiatric hospital for Middle Tennessee region]. Ct is refusing all meds, psych and medical. Ct's nursing facility is refusing to take ct back w/o [without] her being stabilized...MCS spoke with [named MSW#1 from ED] who reports that case management is working with ct's insurance to see if they can help in any way..."

Review of Case Management notes dated 7/20/2023 at 11:13 AM revealed, "The writer was asked to write a current update in the patients status. The patient has been seen by mobile crisis, referred for IP placement, and it was determined she is ineligible for treatment due to being out of Medicare days...The patient has been seen by the rounding psychiatrist [named Physician #1] who is aware of the current presentation, and is unable to justify changing medications due to her refusing all medications. Since her arrival at this facility, the patient has not been combative...but has remained speaking in an incoherent manner. She will become angry when called by her name, but will calm herself down when left alone for a few minutes. The facility is not able to force medicate her. At this time, all parties are aware that the patient has not been taken [taking] her medications, and therefore, has not improved. It is the recommendation of case management that the facility request a court order that compels treatment, or authorizes a POA [Power of attorney]...this writer concurs with the plan."

Follow up notes from mobile crisis dated 7/20/2023 at 11:34 AM, revealed, "MCS spoke with [named MSW #1], who reports that Ct's nursing home is now willing to take Ct back if they receive a letter form [named Physician #1]stating he has exhausted all resources and Ct is refusing her meds...[named MSW #1] reports that [named Physician #1] is working on this and Ct should be discharged to her NH once they have reviewed and accepted this letter..."

Physician #1 made an addendum to the 7/20/2023 Psychiatric note at 3:47 PM, "Pt is not a danger to self or others. She can be discharged back to NH [nursing home]."

There was no evidence in the medical record Patient #1 status had changed from the earlier note by Physician #1, or that Patient #1 was stable to be discharged.

Patient #1 was discharged from Hospital #1 back to the nursing facility on 7/30/2023 at 7:37 PM.

Hospital #1 failed to provide stabilizing treatment for a psychiatric emergency medical condition when they discharged Patient #1 back to her nursing facility when she was experiencing an acute psychiatric episode.

4. Review of an EMS trip report dated 7/20/2023 revealed dispatch received a call from the nursing facility at 9:56 PM to transport Patient #1 for emergent care for a "behavioral/psychiatric episode" that began at 8:45 PM, 68 minutes after Patient #1 was discharged from Hospital #1. Review of the EMS narrative revealed, " ...Patient was found laying in facility bed. Patient was alert and confused ...Patient was transferred from bed to stretcher via self-ambulation ...During transport vitals remained stable, due to patient agitation blood glucose was not obtained ...Patient displayed mood changes from calm to agitated ..." Patient #1's care was transitioned to Hospital #1's ED staff on 7/20/2023 at 11:12 PM

Patient #1's triage was initiated at 11:18 PM on 7/20/2023 with chief complaint "...confusion and aggression. Pt left ER at around 1930 [7:30 PM] tonight and was d/c [discharged] back to [named nursing facility]. EMS state facility stated that pt was too confused and combative and sent her back. EMS states pt has not been combative at all en route." Patient #1 was assigned an acuity level 2.

The MSE was initiated at 11:21 PM with the following documented,"...Patient was seen here on July 17 for a similar episode, she remained in the emergency department for possible psychiatric placement until today when she was ultimately dispositioned back to her nursing home. Patient was sent back to the ER immediately...staff reported to EMS that the patient was too confused and combative however this does appear to be her baseline ...Medical Decision making...Depression, schizophrenia, bipolar disorder, dementia, hallucination...psychosis...Rational: ...Overall nontoxic appearance in no acute distress. Will likely require inpatient Geri-psychiatric facility. 6404 signed and on chart....pertinent positive for UTI [urinary tract infection], ordered course of antibiotics for this. Pending placement..."

Patient #1 remained in Hospital #1's ED from 7/20/2023 with 1:1 monitoring 24 hours per day while awaiting placement at an appropriate psychiatric level of care. The medical record documented case management, Access and Mobile Crisis were involved with the case and made referrals to over 20 different facilities from 7/21/2023 to 8/1/2023. Patient #1 continued to refuse all medications.

5. In an interview on 8/16/2023 at 9:30 AM MSW #1 was asked how the decision was made on 7/20/2023 to discharge Patient #1 back to the nursing home. MSW #1 stated, "Physician #1 had seen her [Patient #1]...basically we can't force her to take her meds...it's a chronic thing...placement [inpatient psychiatric care] wasn't an option in that moment [because the patient had no remaining Medicare inpatient psychiatric days]." MSW #1 stated [named RN #1] had talked to the Director of nursing at the nursing home and they agreed to take Patient #1 back if she was not a danger. MSW #1 stated Physician #1 then changed Patient #1's disposition that she could be sent back to the nursing facility. MSW #1 stated RN #1 spoke with the nursing home staff and relayed the information to him. MSW#1 verified he was not in communication with the nursing facility prior to discharging Patient #1.

In an interview on 8/16/2023 at 9:40 AM, the ED Nursing Director stated there were no case management notes from RN #1 describing communication with the nursing home about Patient #1 returning to their facility on 7/20/2023. The ED Nursing Director further verified Patient #1 consistently refused her medications, including those to treat her psychiatric illness, from 7/17/2023 through 7/20/2023.

In an interview on 8/16/2023 at 10:08 AM, RN #1 stated she was a case manager for Hospital #1. RN #1 stated "...her [Patient #1] initial visit [7/17/2023 ED] was for psych [psychiatric] placement but based on insurance...out of psychiatric [hospital] days...". RN #1 stated on 7/20/2023, the Director of Nursing at Nursing facility reported to her in a telephone call if patient was not a danger to herself or others, they would accept her back at the facility. RN #1 stated, "While she was in our care, she was not a threat to anybody..." RN #1 verified she did not document in the medical record her communications with the nursing facility regarding their acceptance of Patient #1 on 7/20/2023.

In a telephone interview on 8/16/2023 at approximately 10:00 AM, Physician #1 was asked what he based his recommendation on to discharge Patient #1 back to the nursing facility on 7/20/2023. Physician #1 stated, "...more of yelling not hitting anybody here...mostly verbal..." Physician #1 stated Patient #1 was disorganized and delusional but was not an immediate threat to herself or others.

Based on policy review, medical record review, emergency medical services (EMS) report, and interview, the hospital failed to ensure transfer documentation was in the medical record for 1 of 22 (Patient #1) sampled patients.

The findings included:

1. Review of the hospitals "Emergency Medical Treatment and Active Labor (EMTALA) policy revised on 2/5/2021 revealed,"...Transfer Procedures: Any transfer of an individual with an EMC (Emergency Medical Condition) must be initiated either by a physician's order with the appropriate Physician Certification...The individual being transferred must be informed of the risks versus the benefits of the transfer. After determining the transfer is appropriate, the individual can be transferred in accordance with the following procedures: 1. Stabilizing Medical Treatment: The hospital shall provide stabilizing medical treatment within its own capacity to minimize the risks of transfer to the individual's health...2. Acceptance by Receiving Hospital: Prior to the transfer, the hospital has obtained acceptance of the patient by the receiving hospital that has available space and qualified personnel...and has agreed to provide appropriate medical treatment...3. Medical Records: The hospital will provide to the receiving hospital all medical records that are available at the time of transfer and relevant to the EMC ...Document of Transfer: Appropriate Transfer documentation, as outlined above, must be included in the patient's medical record. In addition, ED staff including the certifying physician, must complete the Memorandum of Transfer From (MOT), including all required signatures, dates and times. The MOT must accompany the patient to the receiving facility and a copy placed in the patient's medical record, and must comply with the following: Certification of risks versus benefits: The transferring physician must provide a complete picture of the benefits to be expected from appropriate care at the receiving hospital, such as a higher level of care, specialists available, etc., and the risks associated with the transfer..."

2. Review of an EMS trip report dated 7/20/2023 revealed dispatch received a call from the nursing facility at 9:56 PM to transport Patient #1 for emergent care for a "behavioral/psychiatric episode" that began at 8:45 PM, 68 minutes after Patient #1 was discharged from Hospital #1. Review of the EMS narrative revealed, " ...Patient was found laying in facility bed. Patient was alert and confused ...Patient was transferred from bed to stretcher via self-ambulation ...During transport vitals remained stable, due to patient agitation blood glucose was not obtained ...Patient displayed mood changes from calm to agitated ..." Patient #1's care was transitioned to Hospital #1's ED staff on 7/20/2023 at 11:12 PM

3. Medical record review revealed Patient #1's triage was initiated at 11:18 PM on 7/20/2023 with chief complaint "...confusion and aggression. Pt left ER at around 1930 [7:30 PM] tonight and was d/c [discharged] back to [named nursing facility]. EMS state facility stated that pt was too confused and combative and sent her back. EMS states pt has not been combative at all en route." Patient #1 was assigned an acuity level 2.

The MSE was initiated at 11:21 PM with the following documented,"...Patient was seen here on July 17 for a similar episode, she remained in the emergency department for possible psychiatric placement until today when she was ultimately dispositioned back to her nursing home. Patient was sent back to the ER immediately...staff reported to EMS that the patient was too confused and combative however this does appear to be her baseline ...Medical Decision making...Depression, schizophrenia, bipolar disorder, dementia, hallucination...psychosis...Rational: ...Overall nontoxic appearance in no acute distress. Will likely require inpatient Geri-psychiatric facility. 6404 signed and on chart....pertinent positive for UTI [urinary tract infection], ordered course of antibiotics for this. Pending placement..."

Patient #1 remained in Hospital #1's ED from 7/20/2023 with 1:1 monitoring 24 hours per day while awaiting placement at an appropriate psychiatric level of care. The medical record documented case management, Access and Mobile Crisis were involved with the case and made referrals to over 20 different facilities from 7/21/2023 to 8/1/2023. Patient #1 continued to refuse all medications.

On 8/2/2023, Hospital #2 agreed to accept Patient #1 and arrangements were made for EMS to transport Patient #1 to Hospital #2 for inpatient psychiatric treatment. A nursing note dated 8/2/2023 at 2:30 PM revealed, "called report to [named Hospital #2]; got consent from case management and PA [Physician Assistant] for transfer."

Review of a physician order dated 8/2/2023 at 2:44 PM revealed, "...transfer to hospital [named Hospital #2]."

Review of a case management note dated 8/2/2023 at 3:23 PM revealed Hospital #2 had accepted Patient #1 for transfer.

There was no EMTALA Patient Transfer Form or Physician Certification in the medical record for Patient #1's transfer from Hospital #1 to the receiving Hospital #2.

Hospital #2 contacted the EMS dispatch while they were enroute with Patient #1 and reported the Hospital #1 no longer had a bed for Patient #1 on 8/2/2023 at 3:27 PM. EMS returned Patient #1 to Hospital #1 on 8/2/2023, where she remains on med surge in outpatient bedded status, awaiting inpatient placement at a psychiatric facility.

4. In an interview on 8/16/2023 at 11:49 AM the ED Nursing Director verified there was no documentation of any transfer forms for Patient #1 on 8/2/2023. The ED Director further verified the EMTALA Transfer packet should be documented for all transfers. On 8/21/2023 at 11:00 AM the ED Nursing Director again verified she had been unable to find documentation of the transfer dated 8/2/2023 for Patient #1 to Hospital #2.